Medical Family Therapy in a Primary Care Setting: A Framework for Integration

As the profession of marriage and family therapy (MFT), as well as the emerging sub-specialty of medical family therapy (MedFT), continue to grow and evolve within the current healthcare system, the arena of integrated primary care (IPC) presents an ideal environment for professionals who are relationally and systemically inclined. Although there has been a inundation of literature detailing collaborative systems of healthcare, several gaps still exist: (a) a lack of horizontally integrated models (i.e., models that do not target specific diseases or demographic populations), (b) a lack of model utilization regardless of disease trajectory (i.e., decline, stabilization, improvement), and (c) a lack of IPC models explicitly utilizing MedFT/MFTs as the mental health providers within the system. In lieu of these gaps, the authors present a framework for IPC, utilizing MedFTs/MFTs, that is neither population nor disease specific, as well as a model geared towards implementation regardless of disease trajectory. The framework, which was obtained using ethnography of communication, details MedFTs?? interactions with front line medical providers and patients from initial contact through coordination of a shared treatment plan. Recommendations for future research studies incorporating the use of MedFTs in integrated primary care settings are extended in the context of a three world view framework (Peek in Collaborative medicine case studies: Evidence in practice. Springer, New York, pp 25?C38, 2008; Peek and Heinrich in Family Syst Med 13:327?C342, 1995, Integrated primary care: the future of medical and mental health collaboration. Norton, New York, pp 167?C202, 1998).     

The Benefits of Interprofessional Collaboration for a Pharmacist and Family Therapist

Abstract

Medical family therapists (MedFTs) and pharmacists in the context of interdisciplinary collaboration will be discussed. In an effort to build and reflect on their own professional experiences, recognizing the need to address wellbeing from a multitude of perspectives, and with the goals of improving access to care by identifying potential partnership opportunities between the two professions, the authors synthesized findings from pertinent articles using Medline and PsycInfo. This paper will illuminate the precise roles of MedFTs and pharmacists, how they fit into the interdisciplinary healthcare team, and anticipated facilitators and barriers in this undertaking to enhance patient care.     

Beyond Resilience: Glimpses into Women’s Posttraumatic Growth after Experiencing Intimate Partner Violence

Abstract

Little focus is given to the pathways victims of intimate partner violence (IPV) use to move toward posttraumatic growth. A sample of 32 female participants was recruited through advertising in domestic violence shelters. Women were interviewed about their experiences with four main themes emerging from women’s narratives related to posttraumatic growth: deliberateness of action, ending the cycle for the children, a changed perspective on life, and alternative perceptions of social support. Opportunities for professions working with this population in a number of various of settings is presented to promote long-term changes for women affected by IPV.     

A Model Psychosocial Support Training and Workshop during a Medical Mission for Syrian Refugee Children in Jordan: Techniques,Lessons Learned and Recommendations

ABSTRACT

This article describes a model training and workshop for volunteers that was implemented with child refugees in Jordan, to build empowerment, resilience, and connection with others. The importance of such services for this population is emphasized. The present model, with elements of arts activities and play similar to those used in the Child Friendly Spaces, is based on my extensive experience working with diverse populations under various conditions of crisis, natural disaster, and infectious diseases, mainly in low resource settings. I review activities from my toolbox, their purpose, methods, and processing. The clinical value of such psychosocial support is presented, as has been shown by pilot research in several settings, despite limitations of conducting empirical assessments, which are discussed. Lessons learned and recommended are given. The intervention for refugee children is presented in the context of international policy agreements that provide an important foundation for such projects that clinicians and researchers can use to support their work for this population and others, in efforts to heal children from the traumas of refugeeism and other similar extreme stresses.     

Manualized Treatment of Panic Disorder in a Medical Setting: Two Illustrative Case Studies

People who experience panic attacks (PAs) typically present to medical settings, concerned that their symptoms signify a life-threatening condition. Despite the efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD), medical practitioners seldom provide this type of treatment. Physicians may lack the time or expertise to impart such behavioral medicine interventions, while patients may find group or individual CBT too costly even when available. Researchers have begun investigating manualized CBT as a cost-effective alternative when traditional forms of this intervention are prohibited. This article describes two case studies in which women presenting to a medical clinic with PD were treated with 6 weeks of manualized CBT after pharmacotherapy was unsuccessful or unpalatable. Both patients exhibited reductions in panic and depressive symptomatology over baseline levels, along with increases in self-efficacy regarding their ability to manage future PAs. Improvements were maintained over 12 months, supporting continued use of manualized CBT as a supplement or alternative to pharmacological methods of treating PD in the medical setting.     

Mental Health Services Preparing for the Psychological Consequences of Terrorism

Summary

The Israeli population has been subjected to the stresses of war and terrorist attacks since long before the state was founded. Confronting this extensive experience of terrorism-related psychological trauma, the Mental Health Services of the Ministry of Health designed and implemented a comprehensive emergency response system that operates in general hospitals and community settings to meet the psychological needs resulting from terrorism at both the individual and the population levels. This article describes general premises, basic elements, administrative structure and functioning of this system, as well as training programs for various service providers working with the victims.     

Application of the APA ethics code for psychologists working in integrated care settings: Potential conflicts and resolutions

ABSTRACT

Increasingly, there is evidence of the potential benefits of an integrated care model. In fact, the American Psychological Association (APA) supports the role of psychologists in integrated healthcare given the positive outcomes for patients in primary care settings such as increased access to mental health services, reduced mental illness stigma, and improved health associated with recognizing the impact of psychosocial factors on physical wellbeing. Less attention has been paid, however, to ethical dilemmas that may arise for psychologists working in integrated healthcare. This paper explores considerations for resolving potential ethical conflicts that may arise for psychologists working in integrated care settings.     

Children and Adolescents with Medically Unexplained Symptoms: A Systematic Review of the Literature

Abstract

Medically unexplained symptoms (MUS) in children and adolescents are confounding and concerning for patients, parents, and health care practitioners. Our goal was to review and summarize the literature for family therapists working with a diverse, challenging patient population coping with MUS. A search of multiple databases from 1994 to 2018 was conducted using MUS and related terms. The literature was then organized into subcategories based on its relevance to family therapists, particularly medical family therapists collaborating with primary care physicians. We conclude with a discussion about gaps in the literature and suggestions for clinical management.     

Differential association between food craving,food addiction and eating-related characteristics in persons at risk for eating disorders

IntroductionFood craving is a key feature of eating disorders, but its association with medical and psychological outcome might depend on the type of eating disorder.ObjectivesThis study investigated the factors associated with food craving in individuals at risk for DSM-5 eating disorder.MethodSeventy-six women were recruited from a non-clinical population (n = 372) based on their positive screening (EDDS, QEWP-R) for binge eating disorder (BED; n = 29), anorexia nervosa (AN; n = 28) or bulimia nervosa (BN; n = 19). They completed self-administered questionnaires assessing food craving (FCQ- T-r), Body Mass Index (BMI), eating behaviour (DEBQ), food addiction (YFAS 2.0), and anxiety and depressive symptoms (HADS).ResultsIndividuals at risk for BED or BN had higher food craving than those at risk for AN. Food craving was associated with BMI only in the BED group. Food craving was positively correlated with external eating in all groups, and with emotional eating in the AN and BED groups and correlated with anxiety only in BN. Food addiction prevalence was higher in the BN group than in the AN or BED groups (respectively 94.7%, 46.4% and 65.5%; p < 0.01). In this non-clinical population, we demonstrated that food craving was differentially associated with BMI and eating-related characteristics according to the type of eating disorder.ConclusionThis suggests that food craving is a transdiagnostic dimension that should be differentially targeted depending on the type of eating disorder; future studies should test this hypothesis in clinical populations.     

Inhibition and working memory in young preschool children with symptoms of ADHD and/or oppositional-defiant disorder

Background: Early symptoms of attention deficit/hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) are associated with deficits in cognitive self-regulatory processes or executive functions (EF)s. However, the hypothesis that neurocognitive deficits underlying the two disorders are already evident during early preschool years still has limited empirical support. The present study investigated associations between symptoms of ADHD and/or ODD and two core EFs, inhibition and working memory, in a large nonclinical sample of 3-year old children. Method: Participants were 1045 children (554 boys, age 37–47 months), recruited from the population based Norwegian Mother and Child Cohort Study (MoBa). Relations between behavioral symptoms and measures of inhibition and working memory were studied both categorically and dimensionally. Results: Children with co-occurring symptoms of ADHD and ODD performed at a significantly lower level than typically developing children in 4 out of 5 EF measures. Symptoms of ADHD, both alone and in combination with ODD, were associated with reduced performance on tests of inhibition in the group comparisons. Dimensional analyses showed that performance within both EF domains contributed to variance primarily in ADHD symptom load. The associations between test results and behavioral symptoms remained significant after gender and verbal skills had been controlled. Conclusion: Young preschoolers show the same pattern of relations between EF and behavioral symptoms of ADHD and/or ODD as previously described in older children diagnosed with ADHD and/or ODD. Effect sizes were generally small, indicating that measures of EF have limited clinical utility at this stage in development.     

Comorbid interpretation and expectancy bias in social anxiety and alcohol use

Background: In two studies, the present research examined whether being high in both social anxiety and alcohol use disorder symptoms is associated with a comorbid interpretation and expectancy bias that reflects their bidirectional relationship.

Design: Cross-sectional, quantitative surveys.

Methods: Measures of social anxiety and alcohol use disorder symptoms, as well as an interpretation and expectancy bias task assessing biases for social anxiety, drinking, and comorbid social anxiety and drinking.

Results: In Study 1 (N?=?447), individuals high (vs. low) in social anxiety had stronger social threat bias and individuals high (vs. low) in alcohol use disorder symptoms had stronger drinking bias. Those high in both social anxiety and alcohol use disorder symptoms endorsed interpretations and expectancies linking social interaction with alcohol use. Comorbid bias predicted membership into the high social anxiety/drinking group, even after taking into account single-disorder biases. In Study 2 (N?=?325), alcohol use disorder symptoms predicted drinking bias and social anxiety symptoms predicted social anxiety bias. Alcohol use disorder symptoms, social anxiety symptoms, and their interaction predicted comorbid interpretation and expectancy bias.

Conclusion: Results indicate unique cognitive vulnerability markers for persons with comorbid social anxiety and alcohol use disorder symptoms, which may improve detection and treatment of this serious comorbidity.     

Family Therapy for Substance Use among Sexual Minority Youth: A Review of Treatment Options

Abstract

Substance use disorders are nearly twice as common among sexual minority youth (SMY) as among their heterosexual peers. Most applied literature about this population suggests interventions on either the individual or community level, and the benefits of family therapy for this population are often overlooked. The present literature review (a) outlines clinical knowledge related to sexual minority youth and substance use (e.g., prevalence rates, contributing factors), (b) discusses the importance of clinical self-awareness around these topics, and (c) outlines clinical behaviors and interventions from literature that may be employed when working with substance-using SMY and their families.     

A Systemic Treatment of Families with a Child Diagnosed with Autism Spectrum Disorder Using a Narrative Lens

Abstract

Autism Spectrum Disorder (ASD) is a neurodevelopment disorder that now affects one in 59 children, a 15% increase from the 2012 report. Although there have been numerous studies on the treatment of ASD, interventions focus primarily on the individual diagnosed with ASD. Marriage and family therapists’ (MFT) are in a unique position to handle the systemic dynamics of ASD. As a result, many MFTs find it difficult and outside their scope of practice to work with these families. We will explore aspects of narrative family therapy, conceptualization, and interventions, giving the reader a base understanding of how to implement narrative therapy while working with this population.     

Doing Psychotherapy with Patients with Genital Herpes: Issues and Interventions

Abstract

This article presents issues that the psychotherapist is likely to have to deal with in treating patients with genital herpes. A review of medical issues, clinical manifestations and pharmacotherapy of herpes infections is presented. Common psychological reactions and psychopathology related to herpes simplex virus infection, a discussion of the patient's dilemma of disclosing his or her herpes simplex positive status to others and a list of cognitive-logical distortions often encountered in, and negatively affecting, patients with genital herpes are presented in detailed examples. A practical model (SANE) conceptualizing psychotherapy for patients with genital herpes in 4 intervention stages (Stabilization-crisis intervention, Acceptance, Normalization and social-personal Empowerment-evolution) is suggested for use. The use of cognitive-behavioral therapeutic strategies in facilitating the patient's assumption of a healthier psychosocial perspective in each stage is comprehensively detailed. Ethical and legal concerns in working with herpes simplex positive patients are also discussed.     

Physical activity does not provoke panic attacks in patients with panic disorder: A review of the evidence

Abstract

This paper summarizes the results of published studies in which physical activity has been performed by patients with panic disorder. Several case studies of apparent exercise-induced panic attacks were found. However, in field studies that involved ambulatory monitoring of panic disorder patients only 1 of 91 panic attacks that were monitored actually occurred while the test subject was engaged in moderately intense physical activity. Moreover, only five panic attacks occurred in association with 444 exercise bouts performed by 420 panic disorder patients in laboratory settings despite the fact that exercise induces somatic signs and symptoms of anxiety. Thus, the weight of the published evidence shows that acute physical activity does not provoke panic attacks in panic disorder patients.     

Augmenting Diaphragmatic Breathing With Behavioral Exposure: Single-Case Experimental Design for Rumination Disorder

ObjectiveRumination disorder (RD) is a feeding/eating disorder and disorder of gut-brain interaction characterized by repeated, effortless regurgitations. Diaphragmatic breathing is the most widely used treatment technique for RD, theoretically as a competing response to the habitual contraction of the abdominal wall. However, in light of diaphragmatic breathing’s lack of effectiveness for some patients, we created a comprehensive treatment to test the incremental effect of behavioral exposure on symptom change.MethodIn a single-case experimental design, we present the treatment of a 27-year-old patient with a 9-year history of untreated RD. The patient completed a comprehensive six-session cognitive-behavioral treatment for RD, comprising a 1-week phase of self-monitoring regurgitations + psychoeducation (Phase A), a 6-week phase of diaphragmatic breathing (+ identification of secondary maintenance mechanisms) (Phase B), and a 3-week phase of diaphragmatic breathing + behavioral exposure (Phase C). We compared change in daily symptom data between Phases B and C, and also report 20-month follow-up data.ResultsThe patient’s daily regurgitation frequency did not change during Phase B (diaphragmatic breathing alone), even with the elimination of foods that had become associated with regurgitations. However, she achieved a significant reduction in regurgitations during Phase C, with symptom remission extending to 20-month follow-up. Phase C included purposefully breaking learned associations with food stimuli using behavioral exposure.ConclusionsOur data suggest that when diaphragmatic breathing alone is not effective in reducing symptoms, further cognitive and behavioral techniques like behavioral exposure can augment the effect of diaphragmatic breathing on symptom reduction.     

Community-Clinic-Based Parent Intervention Addressing Noncompliance in Children With Attention-Deficit/Hyperactivity Disorder

The current study tested whether an abbreviated version of Defiant Children (Barkley, 1987), an efficacious parent training program to address the behavioral noncompliance often associated with disruptive behavior disorders, could be implemented successfully within a community mental health clinic setting by master's-level therapists. Ethnically and socioeconomically diverse parents of 16 children (ages 4 to 12 years old) completed a 6-session active treatment group emphasizing the use of differential attending skills, effective time-out strategies, and a structured reinforcement schedule to increase child compliance. Pre- and posttreatment measures of attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), and conduct disorder (CD) symptom level were administered, as well as a measure tapping the contextual breadth (i.e., number of settings) and severity of disruptive behaviors. Parent satisfaction with the treatment was also assessed. Analyses indicated large treatment effects on all measures except CD behavior. Results are discussed in the context of implementing empirically supported therapies in settings where “treatment as usual” is the norm.     

Alternative Methodologies in Research Literature Review: Links Between Clinical Work and MFT Effectiveness

Traditionally, "good outcome research" has referred to laboratory-based, controlled studies that report the efficacy of a given treatment on a specific population. Although useful and needed in the struggle to establish MFTs as accepted mental health service providers, this type of research does not address whether MFT is effective in "real world" settings. In order to highlight the clinical and professional relevance of existing effectiveness research, this article reviews 15 years of clinical research in three major family therapy journals. The results suggest that 1) MFT effectiveness is under-represented in major review articles, 2) clinicians can use a variety of methodologies to establish the effectiveness of their work, and 3) more research is needed that investigates how and why MFT works in "real world" settings. Implications for practice and future research are discussed.     

Development of a Brief Cognitive Screen for Mild Cognitive Impairment and Neurocognitive Disorder

Abstract

The purpose of this study was to develop and evaluate a brief cognitive screen for possible Mild Cognitive Impairment (MCI) and other neurocognitive impairment in a sample of general medical patients. Two hundred community-dwelling general medical patients aged 65 or older participated in this study. Age and education corrected scores from the Rey Auditory Verbal Learning Test and Mattis Dementia Rating Scale were used to classify participants into three groups: MCI, neurocognitive disorder, cognitively intact. Groups were then compared on an independent set of measures: the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) neuropsychological battery, Mini-Mental State Examination, and Clock Drawing Test. The MCI group constituted 9% of the sample, while 10.5% of the sample was classified into the neurocognitive disorder group. The CERAD Verbal Category Fluency and CERAD Word List Memory Test Delayed Recall measures were individually and collectively the most effective in differentiating cognitively intact elders from persons in both the MCI and neurocognitive disorder groups. We conclude that these two brief measures appear to be effective for detecting possible MCI or neurocognitive disorder, thereby facilitating identification of candidates who would benefit from more detailed neuropsychological assessment.     

The Use of Metaphors with African-American Couples

SUMMARY

There is a dearth of data in the literature on African-American couples. This omission probably reflects the assumption that interventions that are effective with one race are effective with others. This paper explores the use of metaphor as a tool for working with an underserved and neglected population. Since the African-American culture is extensive in its use of metaphor, this medium provides a fertile channel for therapeutic communication.